Near Miss Report! Your Name(*) Please let us know your name. Your Contact Number(*) Please let us know your contact number Your Email Please let us know your email address. Site location where you are primarily based(*) Cavan Dublin Louth Meath Offaly Waterford Invalid Input Where did it occur?(*) Date and time of the near miss(*) Invalid Input Date and time of first reporting the near miss if applicable Invalid Input Name of person previously reported to if applicable Please let us know your name. Please choose all options that apply to the incident(*) Chemicals Confined space Cuts Electrical Hit by moving object Machinery Manual handling Other Slips, Trips, Falls Tools / Equipment Vehicles Invalid Input Please describe if Other was selected Please let us know your message. Please provide as much detail as possible about the incident you are reporting(*) 0 Please let us know your message. Please include as much information as possible to help describe the scenario and conditions (e.g. weather, traffic, names of people present etc) Attach Incident files such as photos Add another file Invalid Input How could the near miss be avoided Please let us know your message. Submit Reset form
